Elsevier

The Lancet

Volume 370, Issue 9595, 13–19 October 2007, Pages 1370-1379
The Lancet

Health Policy
Generation of political priority for global health initiatives: a framework and case study of maternal mortality

https://doi.org/10.1016/S0140-6736(07)61579-7Get rights and content

Summary

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.

Introduction

Global health initiatives vary in the amount of political priority they receive from international and national leaders. Child immunisation, family planning, and HIV/AIDS, for instance, at some points have attracted great resources, whereas malnutrition and pneumonia have received little attention despite also addressing high-burden disorders. We know little about the sources of variance in priority levels afforded to global health initiatives, since there is an absence of systematic research into this subject.

We propose an initial framework for analysing the determinants of political priority for global health initiatives, and we hope future researchers will modify and improve this framework. It consists of four categories: the power of actors involved, the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the global safe motherhood initiative, which was launched in 1987 to reduce levels of maternal mortality. This initiative reached its 20th anniversary in 2007, but despite determined efforts by advocates, it has yet to attract the level of political attention its founders hoped it would receive. A recent study on political priority for maternal mortality reduction took the country as the unit of analysis and developed a framework that sought to explain variance in levels of national priority for safe motherhood in Guatemala, Honduras, India, Indonesia, and Nigeria.1 Our study asks a similar question about variance in political priority levels, but the unit of analysis is the global health initiative. It deepens and expands the first framework by grounding it in the extensive research on collective action.

A global initiative is an organised effort linking people and organisations across national borders to address an issue of international concern, such as climate change or human rights. Global political priority is the degree to which international and national political leaders actively give attention to an issue, and back up that attention with the provision of financial, technical, and human resources that are commensurate with the severity of the issue. We know that global political priority is present when: (1) international and national political leaders publicly and privately express sustained concern for the issue; (2) the organisations and political systems they lead enact policies to address the problem; and (3) these organisations and political systems provide levels of resources to the problem that are commensurate with its severity. These three factors include not only international but also national components, since global initiatives rarely aim to generate priority only among international organisations—they also seek political support from national political systems.

Global political priority alone is not sufficient to address an international problem successfully. Effective policies, technology, and implementation systems, among other elements, are also crucial. However, global political priority aids success, and therefore is essential to investigate.

In this paper we present the framework, examine determinants of global political priority for safe motherhood with reference to this framework, point to challenges that the initiative might face in gaining priority over the coming decade, and identify questions for future research into sources of political priority for global health initiatives.

Section snippets

Framework for determinants of political priority for global initiatives

Researchers have sought to understand why initiatives pursuing social and political change succeed or fail in attracting political support. They have investigated several types of collective action efforts, including international networks for issues such as climate change,2, 3, 4, 5, 6 social movements for causes such as civil rights,7, 8, 9, 10 and policy communities that aim to place particular issues on national agendas.11, 12, 13 A central concern in collective action research is the role

Methods used to apply framework

To examine the global safe motherhood initiative we used process-tracing, which is a method that is commonly used in qualitative social science inquiry and involves analysis of several sources of information to uncover social processes and assess causality.27 In 2005–07, we conducted 23 interviews, lasting on average 1·5 h, with individuals centrally involved in the development of the global initiative, including most of its founders. All individuals had worked on safe motherhood with a UN

The case of safe motherhood

In 1987, the World Bank, WHO, and the UN Population Fund (UNFPA) sponsored a conference in Nairobi, Kenya, which launched the Global Safe Motherhood Initiative.37 Its aims were to raise awareness of the roughly half a million yearly maternal deaths worldwide, nearly all of which occurred in developing countries, to spark efforts to address this problem, and to reduce maternal mortality levels by half by the year 2000. After the conference, an Inter-Agency Group for Safe Motherhood (IAG) formed

Factors shaping global political priority for safe motherhood

If we consider all the four categories of factors that affect the acquisition of global political support, we see that the safe motherhood initiative has had many difficulties. With respect to actors, the global policy community has been fragmented, no powerful institutions have emerged to guide the initiative, and organisational rivalries have persisted throughout its history. Additionally, although the initiative included highly capable individuals, it never found a recognised leader.

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